Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Facility staff failed to implement physician orders for Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer and a urinary catheter. The resident's medical record indicated the need for gloves and gowns during high-contact care activities such as dressing, bathing, toileting, personal hygiene, transferring, changing linens, and wound care. Despite these orders, observations revealed that a CNA and an LPN provided direct care, including incontinence care and wound care, without donning gowns as required by EBP protocols. Additionally, the unit manager assisted with repositioning the resident without wearing a gown, even though she acknowledged the resident required EBP due to wounds and catheter use. The need for EBP was not posted at the resident's door. The resident was found with a large, non-blanchable area and an open wound on the buttocks, and the wound had significantly worsened between assessments. The resident also experienced issues with catheter placement, resulting in urine backflow and soiled clothing and bedding. Staff failed to maintain EBP during these care activities, as observed by surveyors, and the required precautions were not consistently communicated or posted for staff awareness.